You are on page 1of 1

LORMA COLLEGES Carlatan, City of San Fernando, La Union (072) 700-2500, Fax Number 242-3628, Lorma.

org (ACSCU-AA1 Level III RE ACCREDITED STATUS valid until April 2017)

ODC Form 1A ASSISTED DELIVERY FORM

ACTUAL DELIVERY in ITRMC, Parian, San Fernando City, La Union

Prepared by: Paul John S. Balancio Student


Date Performed and Time Started Patients INITIAL Case Number PROCEDURE PERFORMED ASSISTED DELIVERY

Signature of the Student ____________________________

D.R. Nurse on Duty

SUPERVISED BY

July 18, 2013 7:35 PM

E. M. 2013- 0018007

Normal Spontaneous Delivery

Anna Glenn J. Consolacion, RN

Helen S. Lubiano, RN, MAN

July 25, 2013 5:29 PM

M. S. 2013- 0018565

Normal Spontaneous Delivery

Anna Glenn J. Consolacion, RN

Helen S. Lubiano, RN, MAN

July 26, 2013 10:06 PM

J. D. 20120007882

Normal Spontaneous Delivery

Anna Glenn J. Consolacion, RN

Helen S. Lubiano, RN, MAN

Noted by: Araceli F. Surat Clinical Coordinator PRC I.D. No. 0244232 Valid Until: October 22, 2014 Date Document is signed: ____________ Time: _________ Highest Nursing Degree Earned: MAN

Approved by: Ludivina D. Magpali Dean PRC I.D. No. 0186484 Valid Until: August 5, 2015 Date Document is signed: ____________ Time: _________ Highest Nursing Degree Earned: MAN